Patient Registration

Thank you for reaching out to us. At this time, Novus Behavioral Health specializes in Psychiatry only. We do not have therapists on staff at this time. The focus of psychiatry is primarily on optimizing medications. Visits take place approximately once per month during medication optimizing phase of treatment. Once medications have been optimized visits take place approximately once every 3 months. Brief supportive psychotherapy is provided during visits.

Psychotherapy, on the other hand, provides counseling only. Visits occur more frequently - usually one hour weekly or biweekly & are longer in duration, usually 50-60 minutes.

In the future, we will offer counseling in addition to medication management.

In the meantime please provide your name & mobile phone number so that we may text you the information of therapists in the area.

Thank you!
Name*

First NameLast Name
Phone Number*

Area CodePhone Number

Name

First NameLast Name
Mobile Phone Number

Area CodePhone Number
Preferred communication method*

TextPhone
Do you agree to receive text communication?*

YesNo
Birth sex*

FemaleMaleOther
Identified gender

FemaleMaleOther
Date of Birth*

MonthDayYear
Date
Social Security Number
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Please select your referral code:
(this would have been provided by your therapist)
Preferred Appt Type*

Online / ZoomIn Person
Preferred Appt Day*
Preferred Appt Time*
Preferred Pharmacy
Reason for your visit:*

Mood DisorderAnxiety DisorderADD/ADHDPTSDKetamineTMSSpravatoOther
Emergency Contact Information
Contact *

First NameLast Name
Contact Relationship
Contact Phone Number

Area CodePhone Number
Payment Information
Preferred Payment Method*

Self PayInsuranceHSA / FSA
Name of Primary Insurance
Primary Insurance Subscriber’s Name
Primary Insurance Subscriber’s Sex

FemaleMale
Subscriber’s Insurance ID number
Group Number
Primary Insurance Effective Date

MonthDayYear
Date
Primary Insurance Subscriber’s Date of Birth

MonthDayYear
Date
Patient’s relationship to subscriber of Primary Insurance

SpouseChildOther
Secondary Insurance Information
Name of Secondary Insurance
Secondary Insurance Subscriber’s Name
Secondary Insurance Subscriber ID number
Secondary Insurance Subscriber’s Date of Birth

MonthDayYear
Date
Secondary Insurance Subscriber’s Sex

FemaleMale
Patient’s relationship to subscriber of Secondary Insurance

SpouseChildOther
Insurance Card & Identification
Front of Insurance Card
Back of Insurance Card
Photo ID
Should be Empty:

Registration Information

Emergency Contact Information

Payment Information

Secondary Insurance Information

Insurance Card & Identification